posterior instability of the shoulder lennard funk
DESCRIPTION
Posterior instability of the shoulder - understanding the pathomechanics, clinical assessment and treatmentTRANSCRIPT
Lennard Funk@theshoulderdoc
PLAN
Posterior instability:!
Pathomechanics!
Diagnosis!
Management !
Results
HISTORY
20th Century!
Plethora of surgical techniques !Poor results (Hawkins, 1984)!Poor understanding
POSTERIOR RESTRAINTS
1. Capsule!
2. Labrum – Posterior Bankart!
3. Glenoid Shape
POSTERIOR LABRUM
POSTERIOR CAPSULE
Thin RHAGL!
Mid-capsule
KIM LESIONSeung-Ho Kim. Arthroscopy. 2004
REDUCED EXTERNAL ROTATION
GLENOID
Version!
Deficiencies
Semogas, Granville-Chapman & Funk, 2014
GLENOID WEAR
POSTERIOR INSTABILITY
1. Traumatic 2. Atraumatic
ATRAUMATIC
Capsular Laxity +/- Muscle Patterning Disorder
TRAUMATIC
Contact sports!
May be minor!
Convulsion
ABER Tackle Direct Impact
Neurological Lesion 32% 15%
Soft tissue Bankart 79% 33%
Bony Bankart 26% 11%
Posterior Labral Tear 11% 50%
SLAP 7% 35%
Partial Cuff Tear 32% 12%
RUGBY SHOULDER INJURIESMalone, Funk, Mohammed, Ball. Shoulder injury patterns in Rugby - the Collision Shoulder. JBJS (Suppl). 2008.
TRADITIONAL TESTS
Specificity Sensitivity Notes Reference
Posterior Drawer Test
No data
Load & Shift 100% 14% For Laxity Gerber & Ganz. JBJSB. 1984
Posterior Apprehension
99% 20% Jia et al. JBJSA. 2009
Jerk Test 85% 90% posteroinf. labral tear
Kim et al. AJSM. 2004
Kim Test 95% 80% posteroinf. labral tear
Kim et al. CORR. 1993
MODIFIED O’BRIEN’S TEST (MOB)!WRIGHTINGTON POSTERIOR INSTABILITY TEST (WPIT)
• Conducted in a similar manner to that initially described by O’Brien
• Patient asked to forward flex the affected arm 90° with the elbow in full extension.
• Adduct the arm fully, medial to the sagittal plane of the body.
• Internally rotate so that the thumb points downward.
• The examiner then applies a downward force to the arm being resisted by the patient.
• The test is considered positive with objective weakness observed by the examiner when downward force on the arm resulted in loss of forward flexion from 90°.
Owen, Mackenzie, Boulter, Funk, 2014
MODIFIED O’BRIEN’S TEST (MOB)!WRIGHTINGTON POSTERIOR INSTABILITY TEST (WPIT)
Owen, Mackenzie, Boulter, Funk, 2014
POSTERIOR INSTABILITY TESTS
Specificity Sensitivity Notes Reference
Posterior Drawer Test
No data
Load & Shift 100% 14% For Laxity Gerber & Ganz. JBJSB. 1984
Posterior Apprehension
99% 20% Jia et al. JBJSA. 2009
Jerk Test 85% 90% posteroinf. labral tear
Kim et al. AJSM. 2004
Kim Test 95% 80% posteroinf. labral tear
Kim et al. CORR. 1993
MOB/WPIT 25% 83% Muscular Athletes
Owen et al. IJSS. 2014
MR ARTHROGRAM
GOLFER’S SHOULDER
MUSCLE EFFECTS
JOINT CAPSULE
EXCESS INTERNAL ROTATION
POSTERIOR STABILISATION
Arthroscopic superseding Open
>85% Success at 2 years !
Lower Morbidity!
Easier Revision!
Treat Associated Pathology:!
Reverse HS; SLAP; Anterior Labrum; Rotator Cuff
OPEN SURGERY
Glenoid bone loss > 25%!
Failed Revision soft tissue repairs!
Massive Reverse Hill-Sachs Lesion!
(Reverse HAGL)
EXAMINATION UNDER ANAESTHESIA
BEACH CHAIR POSITION
PORTALS
POSTERIOR GLENOID BONE LOSS
POST-OP
POST-OP Phase 1: (Level 1 Exercises)
Core stability & Scapula control!
Proprioceptive exercises (minimal weightbearing below 90 degrees)!
Active assisted ROM as comfortable (in 'safe zone' )!
Do not force or stretch
No combined adduction & internal rotation
Phase 2: (Level 2 Exercises)
Progress active assisted to active ROM as comfortable!
Phase 3: (Level 3+ Exercises)
Regain scapula & glenohumeral stability working for shoulder joint control rather than range!
Gradually Strengthen!
Sports-specific rehabilitation - Plyometrics and pertubation training
RESULTS
143 shoulders; 32m FU
Return to Play = 4.3m!
Recurrent Instability = 6/143 (5%)
Badge, Tambe, Funk. Arthroscopic isolated posterior labral repair in rugby players. Int J Should Surg. 2009.
Pre-Op Post-Op Constant Score 65 99 Oxford Score 33 18 Oxford Instability Score 52 13
SUMMARY
Posterior instability:!
Types!
Mechanisms!
Management !
Results
